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題名 | 從「英國前瞻性糖尿病研究」談糖尿病的血糖控制=Blood Glucose Control in Diabetic Patients: The Implication of United Kingdom Prospective Diabetes Study |
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作者 | 曾慶孝; | 書刊名 | 內科學誌 |
卷期 | 9:4 1998.12[民87.12] |
頁次 | 頁169-174 |
分類號 | 415.668 |
關鍵詞 | 英國前瞻性糖尿病研究; 口服降血糖劑; 糖尿病慢性併發症; 血糖控制; 第二型糖尿病; UK prospective diabetes study; Oral hypoglycemic agents; Diabetic chronic complications; Glycemic control; Type 2 diabetes mellitus; |
語文 | 中文(Chinese) |
中文摘要 | 糖尿病是公共衛生上個相當重要的疾病。它的許多慢性併發症是造成臨床上許多 疾病和病人死亡的主要原因。雖然引起糖尿病慢性併發症的真正機轉仍然有待研究,臨床上 醫師必須面對病人的血糖控制,併發症的預防及藥物的選擇與安全性等問題予以處理和解決 。針對第一型的糖尿病病人美國與加拿大近年有「糖尿病控制與併發症試驗」的報告證明血 糖控制的確可以預防小血管慢性併發症的發生,但對大血管慢性併發症的效用則不明確。該 研究亦指出嚴密的胰島素治療會發生頻率較高的低血糖症。針對第二型的糖尿病病人所作的 臨床試驗,美國早期的「大學群糖尿病方案」研究結果不但未發現糖尿病的控制可改善心臟 血管疾病的死亡,反而可能造成傷害,這些結論引起了相當大的震撼和廣泛的討論,最後在 多方指出其研究設計之缺失而導致偏差的結果聲中逐漸被遺忘。一九七○年代英國的學者開 始進行一項稱為「英國前瞻性糖尿病研究」的計畫,做一系列有系統的追蹤研究。一九九八 年九月發表了藥物的使用、血糖的控制、與併發症等相關性的研究結果。該研究採隨機分配 實驗法探討傳統飲食控制及以胰島素注射、 磺醯尿素類口服藥 (包括 chlorpropamide, glibenclamides 及 glipizide) 和雙胍類口服藥 (metformin) 等嚴密血糖控制對三個終點 事件群 (即糖尿病相關終點事件群, 糖尿病相關之死亡,及所有原因死亡 ) 及各單一終點 事件的影響。 在 4,209 位病人長達十年的追蹤結果指出無論以何種方式治療,良好的血糖 控制均可減少小血管慢性併發症的發生。 此外還發現超重的病人以 metformin 治療比以其 它方法嚴密治療有較低的糖尿病相關事件發生 (p=0.0034) , 較低的所有原因死亡 (p=0.021)、及較低的腦中風率 (p=0.032)。 在比較胰島素與磺�s尿素類治療對終點事件群 的影響時, 未發現二者間有差別。 胰島素及磺醯尿素的使用會使體重明顯增加, 但 metformin 則不會。 在比較低血糖發生的頻率時亦發現胰島素和磺醯尿素類較 metformin 高。綜合這些結果我們得到以下的結論:一、無論是第一型或第二型的糖尿病,良好血糖控 制對慢性併發症 (尤其是小血管病變 ) 的預防是非常重要的; 二、沒有證據顯示胰島素或 口服降血糖劑會影響心臟血管疾病;三、Metformin 對超重的病人可考慮為第一線藥物使用 。 |
英文摘要 | Diabetes mellitus is one of the most important diseases in public health. Its chronic complications cause a variety of morbidity and mortality. Although the basic mechanism of these chronic complications is not yet fully known, clinicians still have to face their patients with problems such as blood glucose control, prevention of complications, choices of medications and balancing the risks and benefits of what they use to treat their patients. In the Diabetes Control and Complications Trial, which was carried out in the USA and Canada in type 1 diabetic patients, the importance of blood glucose control in preventing microvascular complications was control of blood glucose with insulin takes the risk of hypoglycemia. University Group Diabetes Programs was an earlier study done in type 2 diabetic patients, aiming at evaluating the effect of blood glucose control, by different therapeutic regimens, on reducing the risk of cardiovascular endpoints. However, this study concluded oppositely by reporting increased risk of cardiovascular mortality in patients allocated tolbutamide or phenformin. These results triggered a vigorous debate and flaws in the design of the study were blamed as leading to biased results. Started in 1977, the United Kingdom Prospective Diabetes Study was deisgned to establish whether, in type 2 diabetic patients, intensive blood-glucose control reduced the risk of macrovascular or microvascular complications, and whether any particular therapy was advantageous. The reports were published recently in September, 1998. It is a multicenter, randomized trial. Patients were allocated to either a conventional treatment policy with dietary control or an intensive treatment policy with insulin, sulphonylurea or metformin. Three aggregate endpoints (i.e. any diabetes-related endpoint, diabetes-related deaths and all-cause mortality) and various single endpoints were monitored and analyzed. After about 10 years, follow-up with 4,209 patients, the results indicated that intensive treatment groups have lower risk of diabetes microvascular complications, regardless whichever regimens were used. Overweight patients allcocated metformin, compared to other regimens of intensive treatment, had lower rates of any diabetes-related endpoint (p=0.0034), all-cause mortality (p=0.021), and stroke (p=0.032). There was no difference for any of the three aggregate endpoints between insulin or sulphonylureas. Insulin and sulphonylureas, but not metformin, caused significant gain in body weight, and more episodes of hypoglycemia. In conclusion, 1)good glycemic control is beneficial in preventing chronic microvascular complications in both type 1 and type 2 patients; 2)neither insulin nor oral agents had an adverse effect on cardiovascular outcomes; 3)metformin may be considered as the first-line pharmacological therapy in overweight type 2 patients. |
本系統之摘要資訊系依該期刊論文摘要之資訊為主。